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CH A NG E PACK AG E
Improving TB screening at Nine TB Diagnostic Treatment Units: Tested Changes and guidance from Uganda
JULY 2018
This change package for improving TB screening in Uganda was prepared by University Research Co., LLC (URC) for review by
the United States Agency for International Development (USAID) and authored by Sylvia Nakibuuka, Herbert Kisamba, and
Esther Karamagi of URC. It was developed as part of the Tuberculosis work in Uganda carried out under the USAID Applying
Science to Strengthen and Improve Systems (ASSIST) Project, which is made possible by the generous support of the
American people through USAID.
THE REPUBLIC OF UGANDA
MINISTRY OF HEALTH
Cover photo: A provider screens a patient for TB. Photo by: Sylvia Nakibuuka, URC.
Improving TB screening at 9 TB Diagnostic
Treatment Units (DTU): Tested Changes and
guidance from Uganda
JULY 2018
Sylvia Nakibuuka, University Research Co., LLC
Herbert Kisamba, University Research Co., LLC
Esther Karamagi, University Research Co., LLC
DISCLAIMER
The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do
not necessarily reflect the views of the United States Agency for International Development or the
United States Government.
Acknowledgements
ASSIST acknowledges local implementing partners for actively participating in the joint coaching,
learning sessions and facilitating the health facility teams. These partners include: Strengthening TB
and HIV responses in the Eastern region (STAR E), Strengthening TB and HIV responses in the East
Central region (STAR EC), Regional Health Integration to enhance Services South West region
(RHITES SW), and TRACK Tuberculosis (TRACK-TB). We thank them.
The authors pass on their gratitude to Knowledge Management team of ASSIST their support in
presenting the changes in this package in a format that enables further learning. We also
acknowledge the Health workers from the 9 DTUs whose results are shared in this document.
This report was prepared by University Research Co., LLC (URC) under the USAID Applying Science
to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people
through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by
URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global
partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T. H. Chan School of Public
Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns
Hopkins Center for Communication Programs; and WI-HER, LLC.
For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or
write [email protected].
Recommended citation
Nakibuuka S, Kisamba H, Karamagi E. 2018. Improving TB screening at 9 TB Diagnostic Treatment
Units (DTU): Tested Changes and guidance from Uganda. Published by the USAID ASSIST Project.
Chevy Chase, MD: University Research Co., LLC (URC).
Improving TB screening at 9 TB Diagnostic Treatment Units i
TABLE OF CONTENTS
I. Introduction ............................................................................................................................................ 1
II. Intervention ............................................................................................................................................ 1
III. Results ................................................................................................................................................... 1
IV. Harvest Meeting ..................................................................................................................................... 3
V. The change package ............................................................................................................................. 3
A. Intended use ......................................................................................................................................... 3
VI. Recommendations ................................................................................................................................. 4
VII. Annex ..................................................................................................................................................... 6
Appendix 1. Rank-ordered changes to improve TB screening for OPD clients ............................................ 6
Appendix 2: List of facilitators during the harvest meeting ........................................................................... 7
Appendix 3: Participating sites and their quality improvement teams .......................................................... 7
ii Improving TB screening at 9 TB Diagnostic Treatment Units
Acronyms
ARI Annual Risk of TB Infection
ART Antiretroviral therapy
ARVs Antiretroviral Drugs
ASSIST Applying Science to Strengthen and Improve Systems project
CME Continuous Medical Education
DTLS District TB Leprosy Supervisor
DTU Diagnostic Treatment Unit
HIV Human Immunodeficiency Virus
IP Implementing partner
KCCA Kampala Capital City Authority
MDR-TB Multi-drug resistant TB
MOH Ministry of Health
OPD Out Patient Department
QI Quality Improvement.
RHITES Regional Health Integration to enhance Services.
SCHW Sub County Health Worker
STAR E Strengthening TB and HIV responses in the Eastern region
STAR EC Strengthening TB and HIV responses in the East Central region
TB Tuberculosis
USAID United States Agency for International Development
Improving TB screening at 9 TB Diagnostic Treatment Units 1
I. Introduction
Uganda continues to notify thousands of tuberculosis (TB) cases (46,171 TB cases in the year 2014)
but these are only half of the estimated TB cases (87,000) (The Uganda National Population Based
Tuberculosis Prevalence Survey 2014-2016). These figures exemplify the progress made but also
highlight the task ahead for Uganda as a country if it is to achieve the new ambitious global target of
ending tuberculosis by the year 2035.
The Annual Risk of TB Infection (ARI) for Uganda remains high, at 3%. The National TB Prevalence
Survey conducted in 2015 puts the incidence of TB at 234/100,000 population for all TB cases and
prevalence of TB is 253/100,000 population. Based on the 2015 Global TB Report, the mortality rate
from TB (excluding HIV positive TB) in 2014 was estimated at 12/100,000 population. Multidrug
resistant TB (MDR-TB) is an emerging problem with more than 1,040 estimated every year and the
actual case finding is around 200 cases per year. (Tuberculosis and Leprosy Manual 3rd Edition
2016). Amidst the high TB burden, the quality of TB services is not at its best with a number of TB
Diagnostic Treatment Units (DTUs) leaving care of TB patients in the hands of low cadre health
workers.
Active TB case finding through improved TB screening at health care facilities increases the number
of persons diagnosed with TB and prevents transmission of TB infection (Ending Tuberculosis by
2030 INT J TUBERC LUNG DIS 20@:1148-1158 2016 The Union).
USAID, through its Applying Science to Strengthen and Improve Systems (ASSIST) project in
Uganda, has since October 2015 worked in collaboration with the ministry of health (MOH) and
implementing partners (IPs) to build the capacity of health workers to screen, diagnose, and manage
TB so as to improve TB care services using the continuous quality improvement (QI) model as well as
the collaborative approach.
ASSIST, together with the MOH and regional IPs provided support to selected health facilities in
Eastern, East Central, Central Kampala Capital City Authority (KCCA), and South Western regions
through conducting eight monthly onsite coaching visits, two learning sessions, and one harvest
meeting to ensure TB care services improved at all the TB supported facilities for a period of eight
months. The experience gained while doing this work is the basis for this change package.
II. Intervention
Following a baseline assessment conducted in October 2015 at the participating health facilities it was
found that TB screening for clients aged 0-14 years attending the out-patient department (OPD) was
at 8.1% and clients aged 15 years and above was at 11.5% at all the sites. ASSIST engaged the
facility-based health workers to review the performance and identify reasons for the observed poor
performance. Regular support through on-site coaching was provided to the facility teams to review
performance and teams came up with service innovations (changes) which they tested to attain
improved TB screening for all clients attending OPD.
During the intervention it was vital for health facility teams to document the process of their
improvement journey, which they did through use of a specific tool called the QI Documentation
Journal. At the start of the intervention health facilities did not have a tool for capturing TB
assessment so the health workers improved by creating a column in the OPD register to cater for that.
However, shortly after the new MOH register that had specific space for documenting TB assessment
findings become available and facilities were all supported to utilize it.
III. Results
TB screening for clients aged 0-14 years attending the OPD was at 8.1% and clients aged 15 years
and above was at 11.5% at all the sites in October 2015. USAID ASSIST engaged the facility-based
health workers to review the performance and identify reasons for the observed poor performance.
Facility teams implemented various changes explained in Table 1 which led to 90% TB screening
2 Improving TB screening at 9 TB Diagnostic Treatment Units
among OPD clients 0-14 years by August 2016 (Figure 1) and 88% for OPD clients above 14 years
(Figure 2).
Figure 1: Percentage of children 0-14 years seen at OPD who were screened for TB at 15 health
facilities (May 2015-Aug 2016)
Figure 2: Percentage of patients 15 years and above seen at OPD who were screened for TB at 15 Health facilities (May 2015-Aug 2016)
Improving TB screening at 9 TB Diagnostic Treatment Units 3
IV. Harvest Meeting
ASSIST held a harvest meeting with the 15 participating health facilities to compile effective changes
that the facilities tested for improving TB screening at the OPD. The facility teams compiled the
changes that they implemented in their facilities. The change ideas were analyzed and made into
change concepts. Using a specific template, the participants described step by step how the changes
were implemented at each facility (Appendix 1). This led to a detailed how to guide of the change
package (Table 1).
The change ideas were further analyzed by the participants to identify those that are related and were
collapsed into change concepts.
V. The change package
A. Intended use
The change package was developed for frontline health workers, IPs, and others engaged in TB care,
especially those working at OPD with the intension of improving TB screening at OPD.
The document has all the changes that were implemented at 9 DTUs. Those intending to use it can
focus on changes that apply to their setting. This change package is intended to provide guidance
among individuals and quality improvement teams wishing to improve TB screening among clients
attending OPD. Teams are urged to adapt these changes to suit their clinic settings for improvement
to occur.
Table 1: Detailed change package for improving TB screening for patients attending OPD at 9
facilities in Uganda
Change Idea Reason for the change How the change happened?
Change concept 1: Building Health workers capacity to screen for TB
Sensitize health workers on TB screening
Some health workers were not updated with TB screening requirements at OPD
• Schedule date for continuing medical education (CME) and communicate to the staff.
• Identify staff with knowledge on how to screen TB using the ICF guide
• Conduct CME with support of the District TB Laboratory Supervisor (DTLS).
• Distribute ICF guides to all care entry points.
• Display ICF guides in all clinicians’ rooms
Displaying of ICF job guides
Health workers needed a quick reference for symptom TB screening
• List out all the necessary TB screening Job aids available for use
• Order missing job aides from the DTLS or IP
• Retrieve available job aides from store.
• Display ICF job aids on table or wall within all clinicians’ rooms
Change concept 2: Assigning specific TB screening roles
Assign a specific staff to oversee TB screening at OPD
No staff was responsible to ensure patients were being screened
• Identify a particular staff at OPD
• Orient him/her about TB screening using ICF guide
• Explained to her/him the roles involved. Some of the roles included; ensuring ICF job aids are available at OPD, review patient records to see if TB status is recorded, reminding other staff about TB
4 Improving TB screening at 9 TB Diagnostic Treatment Units
assessment
Change concept 3: Documenting TB screening data
Writing TB assessment codes alongside patient diagnosis.
TB screening done by clinician but not evidence of assessment.
• Hold meeting to agree on codes to use.
• Identify staff who missed the meeting and orient them on agreed codes
• Team agree to record codes alongside patient diagnosis so that the person recording in the OPD register does not miss it
Continuous verbal reminders to records staff to record patients TB status in OPD register.
Records staff or anyone in OPD forget to record TB status in the OPD register
• Identify member of staff to review register for completeness
• Daily review of OPD register to identify particular staff missing out recording of the TB status
• Focal person or any assigned persons remind record staff to record TB status for every patient and where they lack what to record get to the clinicians to assess the patients
Daily review the OPD register for completeness
TB columns in the OPD registers are blank for Some patients
• Agree of a particular staff to review OPD register daily to check if patients have their TB columns filled out
• Assign staff checks registers daily
• Give feedback on staff who miss some parameters in the register to in-charge by staff assigned to review
• In-charge follow-up staff to establish why and take corrective action
Weekly review of OPD register to check if TB status was recorded.
Some patients have TB columns blank in the OPD register
• Identify a particular staff and assign them to review the OPD registers for completeness of TB column
• Assigned staff choose a convenient day in the week to review OPD register
• Staff review OPD register routinely
• Give feedback to staff who miss filling in the OPD register by OPD in-charge
Change concept 4: Use of Reminders
Pin/ stick reminder notice to ensure OPD clients are screened for TB and TB status recorded in clients’ books and OPD register.
Staff were not screening all OPD clients for TB. And a few who were screened, the TB status was not recorded in the patient book and OPD register
• Print out reminder notes on Manilla paper
• Pin reminder clinical rooms
• Write TB status alongside diagnosis in patients’ books.
VI. Recommendations
These changes are recommended because the 9 health facilities that tested and implemented these
changes reported significant improvement in TB screening for clients attending OPD. Persons
involved in TB work need to focus on:
• Capacity enhancement for health workers: District TB and leprosy supervisors should
regularly enrich health workers with new TB information and new TB job aides during their
Improving TB screening at 9 TB Diagnostic Treatment Units 5
support supervision. The TB job aides should be displayed in areas where they are easily
accessed by all health workers.
• Improving documentation and routine data reviews: The TB team members should
document the findings of the TB assessment process for proper action taking by whoever
sees the patient there after. Use of specific tools that support this like the current version of
OPD register is encouraged. A specific day to review TB data tools for completeness should
be set for the teams to analyze their performance.
• Communicating between providers: All service providers at the facility should be well
versed with TB screening codes, verbally remind health workers who miss recording TB
status in clients’ treatment book.
• Assigning roles: Specific staff should be assigned roles of overseeing TB screening at all
care entry points.
6 Improving TB screening at 9 TB Diagnostic Treatment Units
VII. Annex
Appendix 1. Rank-ordered changes to improve TB screening for OPD clients
Improvement indicator: Percentage of OPD clients screened for TB
Tested change No. of sites
Evidence from Pilot tests
Relative importance
Simplicity/ scalability Affordability
Total rating
Triage staff to review patients TB status and remind health workers 1 5 5 5 5 20.0
Assigning codes to help identify presumptive cases at OPD 1 5 5 5 5 20.0
Continuous reminding of clinicians to screen and dispensers to record patients TB status in OPD register 1 5 5 5 5 20.0
Retrieving and displaying ICF s on all patients care points 1 5 5 5 5 20.0
One on one mentoring to clinicians on TB screening 1 4 5 5 5 19.0
Record TB status along patients’ diagnosis and orient records personal on agreed code 1 5 5 5 4 19.0
Assigned a specific staff to review the OPD register on a weekly basis 3 4 5 4 5 18.0
Assigning a triage staff/nurse to oversee TB screening 2 4.5 4.5 4.5 4.5 18.0
Introduced codes for TB status along patients’ diagnosis 1 3 5 5 5 18.0
Orientation of staff to use TB codes which were recorded along patients’ diagnosis 1 5 5 3 5 18.0
Assigned a focal person to supervise TB assessment and documentation 1 5 5 4 3 17.0
Assigned staff to supervise filling of the OPD register 2 4 4 5 4 17.0
Staff assigned to screen TB in OPD 1 4.5 4 4 4 16.5
Created a column in OPD register to document clients TB status 2 3 3 5 5 16.0
CME conducted to staff on TB screening 3 4 3.25 4.25 4.25 15.8
Conducted a screening of all patients by clinicians 1 3 2 3 9.0
Improving TB screening at 9 TB Diagnostic Treatment Units 7
Appendix 2: List of facilitators during the harvest meeting
Name Title Organization/ District
Dr.Kisamba Herbert Senior Quality Improvement Advisor USAID-ASSIST
Nakibuuka Sylvia Quality Improvement Officer USAID-ASSIST
Birungi Rosette Florence Quality Improvement Officer USAID-ASSIST
Kigonya Angella Knowledge management Officer USAID-ASSIST
Amayo stephen Regional Coach Wakiso district
Masette Elsie Regional Coach Bulabuli district
Tumushabe Belinda Regional Coach Wakiso district
Banturaki Expedito Regional Coach Rubirizi district
Appendix 3: Participating sites and their quality improvement teams
Facility QI team members
Busiu HC IV Dr. Maumbe Benard, Mwiyikinma Emma, Nabulo Janet, Kakai Sylvia, Orena Stephen, Chelogoi Rashid, Wanyana Geofrey, Nambuya Betty.
Nakaloke HC III Wanyenze Bridget, Abwin Christine, Namatome Falida, Wafenya Sam, Arikod Mary, Wakalanga Muhamad, Otunyi Levi, Nandere Margaret, Nagudi Doreen.
Busia HC IV Oduya Betty, Lule Yusuf, Katuutu Christine, Edaku Joseph, Nekesa Getrude
Kityerera HC IV Wabaire Lydia, Gidudu Mariam, Maganda Johson, Bazibu Bosco, Mbera, Sarah, Namuyaga Diana, Magumba Asuman, Kirumira Mutwalibi, Basalirwa Robert, Nabirye Topie.
Nankoma HC IV Magoola Saadi, Bamwose Moses, Musitwa Cloves, Tumwebaze Simon, Kyota Robert
Mutumba HC III Opio Humphrey, Namumbya Faith, Namusoke Mangadalena, Munyori Valeria, Baraka Robert, Othieno Williams, Naigaga Besi
Kanungu HC IV Bagwiza Vincent, Martin Mpimbaza, Katto, Moses Besisira, Kamugisha Augustine, Tuwakire Emily, Tumuramye Justus, Kembabazi Winnie, Musimenta Barbra.
Kyadondo medical centre
Ssekyanzi Maurice, Nalubega Resty, Nakirijja Cissy M.
Nsambya Police clinic
Balaba Luke, Anderu Christine, Nabbona Jane, Sekayise Ronald, Nekesa Harriet
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